Failure to Provide Dental Services as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide dental services as ordered by the physician for a resident with multiple medical diagnoses, including COPD, diabetes, and Crohn's disease. The resident's oral evaluation revealed red and inflamed oral tissue, heavy plaque buildup, and cavities, with recommendations for dental cleaning and assistance with oral hygiene. Despite a dental referral order being placed by the physician due to cavities and subsequent oral pain, there was no documentation that the resident was referred to or seen by a dentist as ordered. The process for handling referral orders required the nurse to confirm the physician's order in the electronic health record, print it, and deliver it to the Appointment Scheduler. However, due to the physician confirming the order directly, the nursing staff were unaware of the referral, and it was not processed as required. The Appointment Scheduler confirmed that no dental referrals for the resident were received or scheduled during the relevant period, despite the presence of orders and ongoing oral health concerns. Interviews with staff and the resident confirmed that the resident had not received the necessary dental follow-up after the initial evaluation and subsequent complaints of oral pain. The facility had not provided onsite dental services for several months, and the breakdown in communication and order processing led to the failure to obtain timely dental care for the resident, as documented in the clinical record and staff interviews.